Care Review Clinician, Prior Authorization Nurse

Molina Healthcare; Long Beach (CA); On-site; USD 60,000 - 95,000; Full time

Job summary

An established industry player in healthcare is seeking dedicated nursing professionals to join their team. This role involves assessing and coordinating care for members with high needs, ensuring compliance with clinical guidelines, and collaborating with multidisciplinary teams. The ideal candidate will have a strong background in clinical service analysis and prior authorization processes. With a focus on quality care and cost-effectiveness, this position offers the chance to make a significant impact on patient outcomes. Join a forward-thinking organization that values your expertise and commitment to healthcare excellence.

Qualifications

• 1-3 years of experience in hospital or medical clinic settings.
• Active nursing license in good standing is required.

Responsibilities

• Assess services to ensure optimum outcomes and compliance.
• Conduct prior authorization reviews and process requests timely.

Skills

Clinical Service Analysis

Prior Authorization Reviews

Collaboration with Multidisciplinary Teams

Knowledge of State and Federal Regulations

Education

Registered Nurse (RN) Program

Licensed Vocational Nurse (LVN) Program

Licensed Practical Nurse (LPN) Program

Tools

Interqual Guidelines

MCG Guidelines

Job description

JOB DESCRIPTION

Job Summary

Molina Healthcare Services (HCS) works with members, providers, and multidisciplinary team members to assess, facilitate, plan, and coordinate an integrated delivery of care across the continuum, including behavioral health and long-term care, for members with high need potential. HCS staff work to ensure that patients progress toward desired outcomes with quality care that is medically appropriate and cost-effective based on the severity of illness and the site of service.

KNOWLEDGE/SKILLS/ABILITIES

• Assesses services for members to ensure optimum outcomes, cost effectiveness, and compliance with all state and federal regulations and guidelines.
• Analyzes clinical service requests from members or providers against evidence-based clinical guidelines.
• Identifies appropriate benefits and eligibility for requested treatments and/or procedures.
• Conducts prior authorization reviews to determine financial responsibility for Molina Healthcare and its members.
• Processes requests within required timelines.
• Refers appropriate prior authorization requests to Medical Directors.
• Requests additional information from members or providers in a consistent and efficient manner.
• Makes appropriate referrals to other clinical programs.
• Collaborates with multidisciplinary teams to promote the Molina Care Model.
• Adheres to UM policies and procedures.
• Occasional travel to other Molina offices or hospitals as requested may be required. This can vary based on the individual State Plan.

JOB QUALIFICATIONS

Required Education

Any of the following:

Completion of an accredited Registered Nurse (RN), Licensed Vocational Nurse (LVN), or Licensed Practical Nurse (LPN) Program.

Required Experience

1-3 years of hospital or medical clinic experience.

Required License, Certification, Association

Active, unrestricted State Registered Nursing (RN), Licensed Vocational Nurse (LVN), or Licensed Practical Nurse (LPN) license in good standing.

Previous experience in Hospital Acute Care, ER or ICU, Prior Auth, Utilization Review / Utilization Management, and knowledge of Interqual / MCG guidelines.

Preferred License, Certification, Association

Active, unrestricted Utilization Management Certification (CPHM).

MULTI STATE / COMPACT LICENSURE

WORK SCHEDULE: Sun - Thurs / Tues - Sat with some holidays.

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.